Need Help with Est. Level-- Need to today please

coder21

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Help Please this is an est patient. Thank you for your time.


Patient with a history of medically complicated obesity, HTN and type 2 diabtes, presenting for weight loss surgery evaluation. Patient has failed multiple attempts of weight loss using conventional methods: dieting, exercising, and commercial weight loss programs. Underwent a 6 month physician supervised weight loss program and meets criteria for bariatric surgery.

Reports significant fatigue for the past few years that interferes with optimal performance of daily activities; however, the patient has noticed significant improvement with lifestyle changes in the past few months.
[].eg

Current medication g3
Medication List Reconciled[].
Farxiga 5 mg tablet take 1 tablet (5 mg) by oral route once daily in the morning[].
Lantus Solostar 100 unit/mL (3 mL) insulin pen inject 36 Units by Subcutaneous route 1 time per day at bedtime[].
Lisinopril 20 mg tablet take 1 tablet by Oral route 1 time per day[].
Lipitor 10 mg tablet 1 tablet by Oral route 1 time per day[].
Amlodipine 10 mg tablet take 1 tablet (10 mg) by oral route once daily[].
Metformin 1,000 mg tablet extended release 24hr take 1 tablet by Oral route 2 times per day[].
BD Insulin Pen Needle UF Mini 31 x 3/16 " needle INJECT 1 Needle by Subcutaneous route 4 times per day[].
Humalog KwikPen 100 unit/mL insulin pen inject 12-24 units by Subcutaneous route 3 times per day before eating[].
Thiamine mononitrate 100 mg tablet 1 tablet by Oral route 1 time per day[].
One-Touch Ultra Test Strips strip TEST 1 Strip by Subcutaneous route 4 times per day Test as directed[].
CPAP Mask & Supplies CPAP of 16 cm H20, full face mask comfort size, large with humidification. DX:327.23 OSA[].eg

Past medical/surgical history g4
Reported:
Surgical / Procedural: Prior surgery Vasectomy Dr. Benz
Circumcision 2010 Dr. Barriocanal
T&A[].
Diagnoses:
Hypertension[].
Hyperlipidemia[].
Type 2 diabetes mellitus insulin[].
Headache syndromes Migraines[]
Migraine headache[].
Depression[]
Sleep Apnea[].
Surgical:
? Otolaryngologic surgery[]
? Sinus surgery[]
? Tonsillectomy[]
? Orthopedic surgery hand[]eg

Review of systems g16
Systemic: Recent weight loss[].
Feeling tired or poorly[]. No fever[] and no chills[].
Head: No headache[].
Neck: No swollen glands in the neck[].
Eyes: No vision problems[] and no blurred vision[].
Otolaryngeal: No nasal passage blockage (stuffiness) -Congestion[]. Snoring[]. No sore throat[].
Cardiovascular: No chest pain or discomfort[] and no palpitations[].
Pulmonary: No shortness of breath[]. No cough[].
Gastrointestinal: No dysphagia[], no jaundice[], no change in stool[], no bright red blood per rectum[], no fecal incontinence[], and no polyphagia[]. No heartburn[]. No nausea[], no vomiting[], no diarrhea[], and no constipation[].
Genitourinary: No inguinal swelling[] and no increase in urinary frequency[]. No dysuria[].
Endocrine: No polydipsia[], no temperature intolerance[], and no hot flashes[].
Hematologic: No easy bleeding[] and no tendency for easy bruising[].
Musculoskeletal: No muscle aches[], no soft tissue stiffness -muscle stiffness[], and no limb pain[].
Arthralgias[]. No soft tissue swelling[]. Stiffness localized to one or more joints[].
Neurological: No memory lapses or loss[], no dizziness[], and no sensory disturbances[].
Psychological: Sleep apnea[]. No anxiety[] and no depression[]. Sleep disturbances[].
Skin: No pruritus[] and no rash[].
Urinary System: Bladder incontinence was not demonstrated[].eg

Physical findings g8
Vital Signs:
Vital Signs/Measurements Value Date
Oral temperature[] 98 10/02/2015
RR[] 18 per min 10/02/2015
PR[] 94 bpm 10/02/2015
Blood pressure[] 148/80 mmHg 10/02/2015
Pain level by numeric rating scale[] 0 10/02/2015
Weight[] 380 lbs 10/02/2015
Body mass index[] 54.5 kg/m2 10/02/2015
Height[] 70 in 10/02/2015
Standard Measurements:
Standard Measurements: Value Date
Body surface area[] 2.9 10/02/2015
Laboratory Studies:
Pulmonary Tests: Value Date
Oxygen saturation[] 97% percent 10/02/2015
Standard Measurements:
? Patient was observed to be obese[].
General Appearance:
? Alert[].
Eyes:
General/bilateral:
? Eyes:[]
Abdomen:
Visual Inspection: ? Abdomen was normal on visual inspection[]. ? Abdomen was not distended[].
Palpation: ? No ascites[]. ? Abdomen was soft[]. ? Abdominal non-tender[]. ? No mass was palpated in the abdomen[].
Liver: ? Not enlarged[].
Neurological:
? Oriented to time, place, and person[].
Psychiatric:
Mood: ? Not depressed[]. ? Not anxious[].
Skin:
? Showed no generalized erythema[]. ? No skin lesions[].
Cardiovascular Disorder:
? Lymphedema[].
Orthopedic Disorder:
? Backache[].
Gastrointestinal Disorder:
? No hernia[].eg

Assessment g11
? Lethargy was observed[]
? Morbid obesity due to excess calories[]
? Type 2 diabetes mellitus without complication[]
? Hypertension[]
? Sleep apnea[]
Patient with medically complicated obesity despite multiple attempts of weight loss with conventional methods. Based criteria, the patient is a good candidate for bariatric surgery. After discussing all the different types of procedures, the patient would like to proceed with a laparoscopic vertical sleeve gastrectomy and possible hiatal hernia repair.
All possible risk and complications, including but not limited to staple line leak or bleeding (2%), sleeve gastrectomy stricture (5%), cardiopulmonary and thromboembolic complications, stroke, infection, malnutrition and weight regain were discussed in detail.
Vitamin levels reviewed. Cardiac and psychological clearances were obtained.
[].eg

Allergies and Adverse Reactions g24
Gabapentin 300 mg capsule. Reaction(s): Upset Stomach, Vomiting. Date Identified: 04/13/2015[].
Allergies Reviewed[].eg

Plan g13
? CBC with differential[]
? Basic metabolic panel with total calcium[]
? Serum vitamin D3 (cholecalciferol)[]
? Follow-up visit 10 day(s)[]
1) Bariatric Liquid Diet 1 week before surgery
2) Discontinue all diuretics 1 week before surgery
3) Discharge instructions and postoperative medication prescriptions provided
4) EKG
5) Follow Up 1 week postoperatively

[].eg
 
Last edited:

LLovett

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This was difficult to read but I come up with a 99214. History appears to be comprehensive, exam I get EPF with 95, MDM I get moderate.

There appears to be conflicting information though. It says no hernia but they may fix a hernia?

Hope this helps,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 

coder21

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Can you explain the moderate? I was thinking low since the fatigue it getting better and the weight is stable. I see the hypertension but it is never address. Don't know if its stable or what.

Thank you for your time.
 

bedforak1

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Can you explain the moderate? I was thinking low since the fatigue it getting better and the weight is stable. I see the hypertension but it is never address. Don't know if its stable or what.

Thank you for your time.
I got Low for the MDM as well. The patient isn't being treated for the HTN, etc.
 
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